a

SISTIM INFORMASI KEMOPROFILAKSIS KUSTA

METODE KONTAK
a TAHUN 2023
PUSKESMAS MUBUNE KABUPATEN MINAHASA UTARA
a

FORMAT ISIAN HASIL REKAPAN GRAFIK

a INFORMASI KASUS INDEKS KEMOPROFILAKSIS KEMOPROFILAKSIS a

a a
KONTAK KASUS KONFIRMASI NON
DESA INDEKS DIAGNOSA KEMOPROFILAKSIS

LAPORAN
REGISTER KONTAK KEMOPROFILAKSIS DATA GRAFIK

a lukman.rhm@gmail.com
ISILAH FORMAT INI DENGAN BENAR DAN LENGKAP

NAMA PROPINSI : SULAWESI UTARA

NAMA KABUPATEN : MINAHASA UTARA

NAMA KECAMATAN : LIKUPANG BARAT

NAMA PUSKESMAS : MUBUNE

NAMA KEPALA PUSKESMAS : dr. DYANA CAROLINE

NIP KEPALA PUSKESMAS : 198811042009032000.00

NAMA PETUGAS KUSTA : NS. MULIA I. TAKALALUMANG, S.KEP

NIP PETUGAS KUSTA : 198811042009032000.00

TAHUN : 2023

TEMPAT PEMBUATAN LAPORAN : PUSKESMAS MUBUNE

LAPORAN BULAN : JULI

 DATA KONTAK KASUS INDEKS MENU

KI.1 KI.2 KI.3 KI.4 KI.5 KI.6 KI, 7 KI. 8 KI. 9 KI. 10

KI 11 KI. 12 KI, 13 KI. 14 KI. 15 KI.16 KI.17 KI. 18 KI.19 KI. 20

KI. 21 KI. 22 KI. 23 KI. 24 KI. 25 KI. 26 KI. 27 KI. 28 KI. 29 KI. 30

KI. 31 KI. 32 KI, 33 KI, 34 KI, 35 KI, 36 KI, 37 KI, 38 KI, 39 KI, 40

KI, 41 KI, 42 KI, 43 KI, 44 KI, 45 KI, 46 KI, 47 KI, 48 KI, 49 KI, 50

KI, 51 KI, 52 KI, 53 KI, 54 KI, 55 KI, 56 KI, 57 KI, 58 KI, 59 KI, 60
 DATA KONTAK KASUS INDEKS MENU

KI.61 KI.62 KI.63 KI.64 KI.65 KI.66 KI, 67 KI. 68 KI. 69 KI. 70

KI 71 KI. 72 KI, 73 KI. 74 KI. 75 KI.76 KI.77 KI. 78 KI.79 KI. 80

KI. 81 KI. 82 KI. 83 KI. 84 KI. 85 KI. 86 KI. 87 KI. 88 KI. 89 KI. 90

KI. 91 KI. 92 KI, 93 KI, 94 KI, 95 KI, 96 KI, 97 KI, 98 KI, 99 KI, 100

KI, 101 KI, 102 KI, 103 KI, 104 KI, 105 KI, 106 KI, 107 KI, 108 KI,109 KI, 110

KI, 111 KI, 112 KI, 113 KI, 114 KI, 115 KI, 116 KI, 117 KI, 118 KI, 119 KI, 120
 ISILAH NAMA DESA / KELURAHAN DAN JUMLAH KASUS IN

JUMLAH KASUS INDEKS YANG DITEM

NO DESA
2019 2020 2021
PB MB TOT PB MB TOT PB MB TOT
1 MUNTE - - -
2 BULUTUI - - -
3 MUBUNE - - -
4 BAHOI - - -
5 SEREI - - -
6 TARABITAN - - -
7 SONSILO - - -
8 TANAH PUTIH - - -
9 JAYAKARSA - - -
10 PAPUTUNGAN - - -
11 TEREMAAL - - -
12 MALIAMBAO - - -
13 PALAES - - -
14 GANGGA 1 - - -
15 GANGGA 2 - - -
16 TAMBUN - - -
17 AIRBANUA - - -
18 TALISE - - -
19 KINABUHUTAN - - -
20 WAWUNIAN - - -
21 . - - -
22 . - - -
23 . - - -
24 . - - -
25 . - - -
JUMLAH 0 0 0 0 0 0 0 0 0
JUMLAH KASUS INDEKS

INDEKS YANG DITEMUKAN TAHUN

2022 2023 TOTAL

PB MB TOT PB MB TOT PB MB TOT
- - - - -

- - - - -

- - - - -

- - - - -

2 2 - - 2 2

- - - - -

- 1 1 - 1 1

- - - - -

- - - - -

1 1 - - 1 1

- - - - -

- - - - -

- - - - -

- - - - -

18 18 1 1 - 19 19

- - - - -

- - - - -

- - - - -

11 11 - - 11 11

- - - - -

- - - - -

- - - - -

- - - - -

- - - - -

- - - - -

0 32 32 0 2 2 0 34 34
 1/2023

PB MB 0
MUNTE 1 PB MB 0
BULUTUI 1 PB MB 0
MUBUNE 1 PB MB 0
BAHOI 1 PB MB 0
SEREI 1 PB MB 0
TARABITAN 1 PB MB 0
SONSILO 1 PB MB 0
TANAH PUTIH 1 PB MB 0
JAYAKARSA 1 PB MB 0
PAPUTUNGAN 1 PB MB 0
TEREMAAL 1 PB MB 0
MALIAMBAO 1 PB MB 0
PALAES 1 PB MB 0
GANGGA 1 1 PB MB 0
GANGGA 2 1 PB MB 0
TAMBUN 1 PB MB 0
AIRBANUA 1 PB MB 0
TALISE 1 PB MB 0
KINABUHUTAN 1 PB MB 0
WAWUNIAN 1 PB MB 0
. 1 PB MB 0
. 1 PB MB 0
. 1 PB MB 0
. 1 PB MB 0
. 1 PB MB 0
 INDEKS PB MB 0
1 2L P
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 2 0 2 2
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 1 0 1 1
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2L P 0 0 0 0
1 2 KONTAK L P

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 2 0 2 22 0 22 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 7 0 7 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 KONTAK YANG DIBERIKAN KEMOPROFILAKSIS KUSTA
PUSKESMAS MUBUNE KABUPATEN MINAHASA UTARA
TAHUN 2023

JUMLAH KONTAK YANG DIBERI RIFAMPISIN KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
£ KASUS INDEKS
ALASAN/ EKSLUSIF KARENA DIAGNOSA
ADA
TYPE KONTAK SEX % SAMPING
NO DESA SUSPEK DALAM
SAKIT GANGGUAN
PERNAH
PERE USIA MINUM SUSPEK TB BENTUK
YANG DI PX MPUA <2 FUNGSI SUSPEK SUSPEK SEBAB KUSTA
SE TE RIF. < 2 BERAT
ADA KONTAK HATI/ KUSTA TB LAIN
TANGGA SOSIAL L P N Thn Thn / MRS
RUMAH TERAKHIR GINJAL POS NEG POS NEG

1 MUNTE - - - - - - - - - - - - - - - - - - -
2 BULUTUI - - - - - - - - - - - - - - - - - - -
3 MUBUNE - - - - - - - - - - - - - - - - - - -
4 BAHOI - - - - - - - - - - - - - - - - - - -
5 SEREI 2 2 10 9 3 11 11 50.0 - - - - - - - - - - -
6 TARABITAN - - - - - - - - - - - - - - - - - - -
7 SONSILO - - - - - - - - - - - - - - - - - - -
8 TANAH PUTIH - - - - - - - - - - - - - - - - - - -
9 JAYAKARSA - - - - - - - - - - - - - - - - - - -
10 PAPUTUNGAN 1 1 2 4 1 2 5 71.4 - - - - - - - - - - -
11 TEREMAAL - - - - - - - - - - - - - - - - - - -
12 MALIAMBAO - - - - - - - - - - - - - - - - - - -
13 PALAES - - - - - - - - - - - - - - - - - - -
14 GANGGA 1 - - - - - - - - - - - - - - - - - - -
15 GANGGA 2 - - - - - - - - - - - - - - - - - - -
16 TAMBUN - - - - - - - - - - - - - - - - - - -
17 AIRBANUA - - - - - - - - - - - - - - - - - - -
18 TALISE - - - - - - - - - - - - - - - - - - -
19 KINABUHUTAN - - - - - - - - - - - - - - - - - - -
20 WAWUNIAN - - - - - - - - - - - - - - - - - - -
21 . - - - - - - - - - - - - - - - - - - -
22 . - - - - - - - - - - - - - - - - - - -
23 . - - - - - - - - - - - - - - - - - - -
24 . - - - - - - - - - - - - - - - - - - -
25 . - - - - - - - - - - - - - - - - - - -
JUMLAH 3 3 12 13 4 13 16 55.2 - - - - - - - - - - -

PUSKESMAS MUBUNE JULI 2023

NEBGETAHUI : PETUGAS KUSTA
KEPALA PUSKESMAS MUBUNE PUSKESMAS MUBUNE

dr. DYANA CAROLINE NS. MULIA I. TAKALALUMANG, S.KEP

NIP. 198811042009032000 NIP. 198811042009032000
 DATA KASUS INDEKS DAN TATA LAKSANA KONTAK
PUSKESMAS MUBUNE KABUPATEN MINAHASA UTARA
TAHUN 2023
JUMLAH KASUS JUMLAH KASUS INDEKS YANG DILAKUKAN % KASUS KASUS INDEKS
TINGKAT CACAT JUMAH DENGAN TATA
INDEKS
NO DESA INDEKS KEMOPROFILAKSIS DILAKUKAN
KONTAK LAKSANA KONTAK
KEMOPROFI KASUS
LAKSIS INDEKS
PB MB TOTAL PB MB TOTAL L P TOTAL 0 1 2 JML %
1 MUNTE - - - - - - - - - - - - - - - -
2 BULUTUI - - - - - - - - - - - - - - - -
3 MUBUNE - - - - - - - - - - - - - - - -
4 BAHOI - - - - - - - - - - - - - - - -
5 SEREI - 2 2 - 2 2 - 2 2 100.0 2 - - 22 2 100
6 TARABITAN - - - - - - - - - - - - - - - -
7 SONSILO - 1 1 - - - - - - - - - - - - -
8 TANAH PUTIH - - - - - - - - - - - - - - - -
9 JAYAKARSA - - - - - - - - - - - - - - - -
10 PAPUTUNGAN - 1 1 - 1 1 1 - 1 100.0 1 - - 7 1 100
11 TEREMAAL - - - - - - - - - - - - - - - -
12 MALIAMBAO - - - - - - - - - - - - - - - -
13 PALAES - - - - - - - - - - - - - - - -
14 GANGGA 1 - - - - - - - - - - - - - - - -
15 GANGGA 2 - 19 19 - - - - - - - - - - - - -
16 TAMBUN - - - - - - - - - - - - - - - -
17 AIRBANUA - - - - - - - - - - - - - - - -
18 TALISE - - - - - - - - - - - - - - - -
19 KINABUHUTAN - 11 11 - - - - - - - - - - - - -
20 WAWUNIAN - - - - - - - - - - - - - - - -
21 . - - - - - - - - - - - - - - - -
22 . - - - - - - - - - - - - - - - -
23 . - - - - - - - - - - - - - - - -
24 . - - - - - - - - - - - - - - - -
25 . - - - - - - - - - - - - - - - -
JUMLAH - 34 34 - 3 3 1 2 3 8.8 3 - - 29 3 100
PUSKESMAS JULI 2023
MUBUNE
MENGETAHUI : PETUGAS KUSTA
KEPALA PUSKESMAS MUBUNE PUSKESMAS MUBUNE

dr. DYANA CAROLINE NS. MULIA I. TAKALALUMANG, S.KEP

NIP. 198811042009032000 NIP. 198811042009032000
 DATA GRAFIK KEMOPROFILAKSIS
PUSKESMAS MUBUNE KABUPATEN MINAHASA UTARA

NON
NO DESA KEMOPROFILAKSIS KEMOPROFILAKSIS

1 MUNTE
- -

2 BULUTUI
- -

3 MUBUNE
- -

4 BAHOI
- -

5 SEREI
100.0 -

6 TARABITAN
- -

7 SONSILO
- -

8 TANAH PUTIH
- -

9 JAYAKARSA
- -

10 PAPUTUNGAN
100.0 -

11 TEREMAAL
- -

12 MALIAMBAO
- -

13 PALAES
- -

14 GANGGA 1
- -

15 GANGGA 2
- -

16 TAMBUN
- -
17 AIRBANUA
- -

18 TALISE
- -

19 KINABUHUTAN
- -

20 WAWUNIAN
- -

21 .
- -

22 .
- -

23 .
- -

24 .
- -

25 .
- -
 PROSENTASE KONTAK YANG DIBERIKAN KEMOPROFILAKSIS KUSTA
PUSKESMAS MUBUNE KABUPATEN MINAHASA UTARA
TAHUN 2023

100.0 100.0
100.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
- - - - - - - - - - - - - - - - - - - - - - -
-

Kontak Yang diberikan Kemoprofilaksis

 PROSENTASE KONTAK YANG TIDAK DIBERIKAN KEMOPROFILAKSIS
PUSKESMAS MUBUNE KABUPATEN MINAHASA UTARA
TAHUN 2023

1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1 - - - - - - - - - - - - - - - - - - - - - - - - -
-
I OI I . . . . .
TE TU NE RE N ILO TIH SA AN AL O ES 1 2 N A
LIS
E N AN
UN U U A H SE ITA S U R G A BA LA GA GA BU NU TA NI
L UB B B N P K A N M M A G G M A TA U U
M BU RA SO AH YA UT
U RE LIA
P
AN AN TA RB BU
H
M
TA N JA P TE A G G AI A AW
TA PA M K IN W

Kontak yang tidak diberikan Kemoprofilaksis

 KONTAK YANG DIBERIKAN KEMOPROFILAKSIS KUSTA
PUSKESMAS MUBUNE KABUPATEN MINAHASA UTARA
TAHUN 2023

JUMLAH KONTAK DIBERI RIFAMPISIN SESUAI

TYPE KONTAK KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN ALASAN/ EKSLUSIF KARENA
KONTAK
NO DESA KASUS PERNAH
SAKIT GANGGUAN
INDEKS SE TE USIA <2 MINUM BERAT/ FUNGSI HATI/ SUSPEK SUSPEK SEBAB TOTAL
SOSIAL TOTAL % RIF. < 2 %
RUMAH TANGGA Thn
Thn MRS GINJAL KUSTA TB LAIN
TERAKHIR
1 MUNTE - - - - - - - - - - - - - - -

2 BULUTUI - - - - - - - - - - - - - - -

3 MUBUNE - - - - - - - - - - - - - - -

4 BAHOI - - - - - - - - - - - - - - -

5 SEREI 22 10 9 3 22 100.0 - - - - - - - - -

6 TARABITAN - - - - - - - - - - - - - - -

7 SONSILO - - - - - - - - - - - - - - -

8 TANAH PUTIH - - - - - - - - - - - - - - -

9 JAYAKARSA - - - - - - - - - - - - - - -

10 PAPUTUNGAN 7 2 4 1 7 100.0 - - - - - - - - -

11 TEREMAAL - - - - - - - - - - - - - - -

12 MALIAMBAO - - - - - - - - - - - - - - -

13 PALAES - - - - - - - - - - - - - - -

14 GANGGA 1 - - - - - - - - - - - - - - -

15 GANGGA 2 - - - - - - - - - - - - - - -

16 TAMBUN - - - - - - - - - - - - - - -

17 AIRBANUA - - - - - - - - - - - - - - -

18 TALISE - - - - - - - - - - - - - - -
19 KINABUHUTAN - - - - - - - - - - - - - - -

20 WAWUNIAN - - - - - - - - - - - - - - -

21 . - - - - - - - - - - - - - - -

22 . - - - - - - - - - - - - - - -

23 . - - - - - - - - - - - - - - -

24 . - - - - - - - - - - - - - - -

25 . - - - - - - - - - - - - - - -

JUMLAH 29 12 13 4 29 100.0 - - - - - - - - -

MENGETAHUI : PUSKESMAS MUBUNE JULI 2023

KEPALA PUSKESMAS MUBUNE PETUGAS KUSTA
PUSKESMAS MUBUNE

dr. DYANA CAROLINE NS. MULIA I. TAKALALUMANG, S.KEP

NIP. 198811042009032000 NIP. 198811042009032000
 JUMLAH KONTAK KASUS INDEKS
PUSKESMAS MUBUNE KABUPATEN MINAHASA UTARA
TAHUN 2023

KASUS INDEKS
NO DESA JUMLAH KONTAK
KASUS INDEKS
PB MB TOT

1 MUNTE - - - -

2 BULUTUI - - - -

3 MUBUNE - - - -

4 BAHOI - - - -

5 SEREI - 2 2 22

6 TARABITAN - - - -

7 SONSILO - - - -

8 TANAH PUTIH - - - -

9 JAYAKARSA - - - -

10 PAPUTUNGAN - 1 1 7

11 TEREMAAL - - - -

12 MALIAMBAO - - - -

13 PALAES - - - -

14 GANGGA 1 - - - -

15 GANGGA 2 - - - -

16 TAMBUN - - - -

17 AIRBANUA - - - -

18 TALISE - - - -

19 KINABUHUTAN - - - -

20 WAWUNIAN - - - -

21 . - - - -

22 . - - - -

23 . - - - -

24 . - - - -

25 . - - - -

JUMLAH - 3 3 29

PUSKESMAS MUBUNE JULI 2023

MENGETAHUI : PETUGAS KUSTA
KEPALA PUSKESMAS MUBUNE PUSKESMAS MUBUNE
 dr. DYANA CAROLINE NS. MULIA I. TAKALALUMANG, S.KEP
NIP. 198811042009032000 NIP. 198811042009032000
 1/2023

MUNTE L P X X
BULUTUI L P X X
MUBUNE L P X X
BAHOI L P X X
SEREI L P X X
TARABITAN L P X X
SONSILO L P X X
TANAH PUTIH L P X X
JAYAKARSA L P X X
PAPUTUNGAN L P X X
TEREMAAL L P X X
MALIAMBAO L P X X
PALAES L P X X
GANGGA 1 L P X X
GANGGA 2 L P X X
TAMBUN L P X X
AIRBANUA L P X X
TALISE L P X X
KINABUHUTAN L P X X
WAWUNIAN L P X X
. L P X X
. L P X X
. L P X X
. L P X X
. L P X X
SEX SERUMAH TETANGGA
L P SOSIAL <2 RIF MRS GINJAL
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
11 11 10 9 3 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
2 5 2 4 1 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
SUSP SUSP SEBAB SUSP KUSTA SUSP TB SEX
KUSTA TB LAIN POS NEG POS NEG L
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 22 0 0 0 0 5 5
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 7 0 0 0 0 0 2
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
 P K TB
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
1 11 5 4 2 11 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 2 2 2 1 5 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
 JUMLAH SUSPEK DAN HASIL KONFIRMASI DIAGNOSA
PUSKESMAS MUBUNE KABUPATEN MINAHASA UTARA
TAHUN 2023

KONFIRMASI DIAGNOSA KONFIRMASI DIAGNOSA

JUMLAH JUMLAH
NO DESA SUSPEK SUSPEK
KUSTA TB
POS NEG TOT POS NEG TOT

1 MUNTE - - - - - - - -

2 BULUTUI - - - - - - - -

3 MUBUNE - - - - - - - -

4 BAHOI - - - - - - - -

5 SEREI - - - - - - - -

6 TARABITAN - - - - - - - -

7 SONSILO - - - - - - - -

8 TANAH PUTIH - - - - - - - -

9 JAYAKARSA - - - - - - - -

10 PAPUTUNGAN - - - - - - - -

11 TEREMAAL - - - - - - - -

12 MALIAMBAO - - - - - - - -

13 PALAES - - - - - - - -

14 GANGGA 1 - - - - - - - -

15 GANGGA 2 - - - - - - - -

16 TAMBUN - - - - - - - -

17 AIRBANUA - - - - - - - -

18 TALISE - - - - - - - -

19 KINABUHUTAN - - - - - - - -

20 WAWUNIAN - - - - - - - -

21 . - - - - - - - -

22 . - - - - - - - -

23 . - - - - - - - -

24 . - - - - - - - -

25 . - - - - - - - -

JUMLAH - - - - - - - -
 C17 Z6 Q5 Q6 Z9

INDEKS
DESA TYPE CACAT KONTAK KODE
CASE
1 PAPUTUNGAN 1 MB 0 1 1
2 SEREI 1 MB 0 1 1
3 0 0 MB 0 1 1
4 SEREI 1 MB 0 1 1
5 0 0 MB 0 1 1
6 0 0 MB 0 1 1
7 0 0 MB 0 1 1
8 0 0 MB 0 1 1
9 0 0 MB 0 1 1
10 0 0 0 0 0 1
11 0 0 0 0 0 1
12 0 0 0 0 0 1
13 0 0 0 0 0 1
14 0 0 0 0 0 1
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL

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2 Dean Alamri PAPUTUNGAN 36 P X 0 0 Z 0 0 0 0 0 0
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7 SISKA KALANGKAHAN PAPUTUNGAN 24 P 0 X 0 Z 0 0 0 0 0 0
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
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18 0 Z
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195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
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55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
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100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN : KONTAK SERUMAH
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
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71 0 Z
72 0 Z
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78 0 Z
79 0 Z
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100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
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109 0 Z
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111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
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129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
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129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
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55 0 Z
56 0 Z
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79 0 Z
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101 0 Z
102 0 Z
103 0 Z
104 0 Z
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106 0 Z
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109 0 Z
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114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
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125 0 Z
126 0 Z
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130 0 Z
131 0 Z
132 0 Z
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135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
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144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
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129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
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129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
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55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
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61 0 Z
62 0 Z
63 0 Z
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67 0 Z
68 0 Z
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71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
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79 0 Z
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81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
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91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
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115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
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125 0 Z
126 0 Z
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130 0 Z
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132 0 Z
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134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
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129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI
U KONTAK YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
ADA EFEK
S KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M SAMPING
NO NAMA ALAMAT U E DALAM
R X PERNAH BENTUK
SAKIT GANGGUAN SUSPEK KUSTA SUSPEK TB
SE TETANGG USIA <2 MINUM RIF. SUSPEK SUSPEK SEBAB
SOSIAL BERAT/ FUNGSI
RUMAH A Thn < 2 Thn KUSTA TB LAIN
MRS HATI /GINJAL
TERAKHIR POS NEG POS NEG

1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : LUKMAN ALAMRI TYPE KUSTA :
ALAMAT : PAPUTUNGAN TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : 2022 TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : YA TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 Debby Tondompato PAPUTUNGAN 38 P X Z
2 Dean Alamri PAPUTUNGAN 36 P X Z
3 NITTA KALANGKAHAN PAPUTUNGAN 31 P X Z
4 NOLDY KALANGKAHAN PAPUTUNGAN 29 L X Z
5 YUNARTI KACOMBO PAPUTUNGAN 39 P X Z
6 REYNOL KALANGKAHAN PAPUTUNGAN 25 L X Z
7 SISKA KALANGKAHAN PAPUTUNGAN 24 P X Z
8 PAPUTUNGAN Z
9 PAPUTUNGAN Z
10 PAPUTUNGAN Z
11 PAPUTUNGAN Z
12 PAPUTUNGAN Z
13 PAPUTUNGAN Z
14 PAPUTUNGAN Z
15 PAPUTUNGAN Z
16 PAPUTUNGAN Z
17 PAPUTUNGAN Z
18 PAPUTUNGAN Z
19 PAPUTUNGAN Z
20 PAPUTUNGAN Z
21 PAPUTUNGAN Z
22 PAPUTUNGAN Z
23 PAPUTUNGAN Z
24 PAPUTUNGAN Z
25 PAPUTUNGAN Z
26 PAPUTUNGAN Z
27 PAPUTUNGAN Z
28 PAPUTUNGAN Z
29 PAPUTUNGAN Z
30 PAPUTUNGAN Z
31 PAPUTUNGAN Z
32 PAPUTUNGAN Z
33 PAPUTUNGAN Z
34 PAPUTUNGAN Z
35 PAPUTUNGAN Z
36 PAPUTUNGAN Z
37 PAPUTUNGAN Z
38 PAPUTUNGAN Z
39 PAPUTUNGAN Z
40 PAPUTUNGAN Z
41 PAPUTUNGAN Z
42 PAPUTUNGAN Z
43 PAPUTUNGAN Z
44 PAPUTUNGAN Z
45 PAPUTUNGAN Z
46 PAPUTUNGAN Z
47 PAPUTUNGAN Z
48 PAPUTUNGAN Z
49 PAPUTUNGAN Z
50 PAPUTUNGAN Z
51 PAPUTUNGAN Z
52 PAPUTUNGAN Z
53 PAPUTUNGAN Z
54 PAPUTUNGAN Z
55 PAPUTUNGAN Z
56 PAPUTUNGAN Z
57 PAPUTUNGAN Z
58 PAPUTUNGAN Z
59 PAPUTUNGAN Z
60 PAPUTUNGAN Z
61 PAPUTUNGAN Z
62 PAPUTUNGAN Z
63 PAPUTUNGAN Z
64 PAPUTUNGAN Z
65 PAPUTUNGAN Z
66 PAPUTUNGAN Z
67 PAPUTUNGAN Z
68 PAPUTUNGAN Z
69 PAPUTUNGAN Z
70 PAPUTUNGAN Z
71 PAPUTUNGAN Z
72 PAPUTUNGAN Z
73 PAPUTUNGAN Z
74 PAPUTUNGAN Z
75 PAPUTUNGAN Z
76 PAPUTUNGAN Z
77 PAPUTUNGAN Z
78 PAPUTUNGAN Z
79 PAPUTUNGAN Z
80 PAPUTUNGAN Z
81 PAPUTUNGAN Z
82 PAPUTUNGAN Z
83 PAPUTUNGAN Z
84 PAPUTUNGAN Z
85 PAPUTUNGAN Z
86 PAPUTUNGAN Z
87 PAPUTUNGAN Z
88 PAPUTUNGAN Z
89 PAPUTUNGAN Z
90 PAPUTUNGAN Z
91 PAPUTUNGAN Z
92 PAPUTUNGAN Z
93 PAPUTUNGAN Z
94 PAPUTUNGAN Z
95 PAPUTUNGAN Z
96 PAPUTUNGAN Z
97 PAPUTUNGAN Z
98 PAPUTUNGAN Z
99 PAPUTUNGAN Z
100 PAPUTUNGAN Z
101 PAPUTUNGAN Z
102 PAPUTUNGAN Z
103 PAPUTUNGAN Z
104 PAPUTUNGAN Z
105 PAPUTUNGAN Z
106 PAPUTUNGAN Z
107 PAPUTUNGAN Z
108 PAPUTUNGAN Z
109 PAPUTUNGAN Z
110 PAPUTUNGAN Z
111 PAPUTUNGAN Z
112 PAPUTUNGAN Z
113 PAPUTUNGAN Z
114 PAPUTUNGAN Z
115 PAPUTUNGAN Z
116 PAPUTUNGAN Z
117 PAPUTUNGAN Z
118 PAPUTUNGAN Z
119 PAPUTUNGAN Z
120 PAPUTUNGAN Z
121 PAPUTUNGAN Z
122 PAPUTUNGAN Z
123 PAPUTUNGAN Z
124 PAPUTUNGAN Z
125 PAPUTUNGAN Z
126 PAPUTUNGAN Z
127 PAPUTUNGAN Z
128 PAPUTUNGAN Z
129 PAPUTUNGAN Z
130 PAPUTUNGAN Z
131 PAPUTUNGAN Z
132 PAPUTUNGAN Z
133 PAPUTUNGAN Z
134 PAPUTUNGAN Z
135 PAPUTUNGAN Z
136 PAPUTUNGAN Z
137 PAPUTUNGAN Z
138 PAPUTUNGAN Z
139 PAPUTUNGAN Z
140 PAPUTUNGAN Z
141 PAPUTUNGAN Z
142 PAPUTUNGAN Z
143 PAPUTUNGAN Z
144 PAPUTUNGAN Z
145 PAPUTUNGAN Z
146 PAPUTUNGAN Z
147 PAPUTUNGAN Z
148 PAPUTUNGAN Z
149 PAPUTUNGAN Z
150 PAPUTUNGAN Z
151 PAPUTUNGAN Z
152 PAPUTUNGAN Z
153 PAPUTUNGAN Z
154 PAPUTUNGAN Z
155 PAPUTUNGAN Z
156 PAPUTUNGAN Z
157 PAPUTUNGAN Z
158 PAPUTUNGAN Z
159 PAPUTUNGAN Z
160 PAPUTUNGAN Z
161 PAPUTUNGAN Z
162 PAPUTUNGAN Z
163 PAPUTUNGAN Z
164 PAPUTUNGAN Z
165 PAPUTUNGAN Z
166 PAPUTUNGAN Z
167 PAPUTUNGAN Z
168 PAPUTUNGAN Z
169 PAPUTUNGAN Z
170 PAPUTUNGAN Z
171 PAPUTUNGAN Z
172 PAPUTUNGAN Z
173 PAPUTUNGAN Z
174 PAPUTUNGAN Z
175 PAPUTUNGAN Z
176 PAPUTUNGAN Z
177 PAPUTUNGAN Z
178 PAPUTUNGAN Z
179 PAPUTUNGAN Z
180 PAPUTUNGAN Z
181 PAPUTUNGAN Z
182 PAPUTUNGAN Z
183 PAPUTUNGAN Z
184 PAPUTUNGAN Z
185 PAPUTUNGAN Z
186 PAPUTUNGAN Z
187 PAPUTUNGAN Z
188 PAPUTUNGAN Z
189 PAPUTUNGAN Z
190 PAPUTUNGAN Z
191 PAPUTUNGAN Z
192 PAPUTUNGAN Z
193 PAPUTUNGAN Z
194 PAPUTUNGAN Z
195 PAPUTUNGAN Z
196 PAPUTUNGAN Z
197 PAPUTUNGAN Z
198 PAPUTUNGAN Z
199 PAPUTUNGAN Z
200 PAPUTUNGAN Z

7 7 2 4 1 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 L
MB
0 PB
SUKARELA MB
###
2022 ###

JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK
SAMPING ###
DALAM
USPEK KUSTA SUSPEK TB BENTUK MENU ###
###
NEG POS NEG ###
###
###
###
###
###
###
###
###
###
###
 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
PINDAHAN
RELAPS
MASUK KEMBALI
GANTI TYPE
###
###
###
###
###
###
###
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###
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###
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###
###
###
###
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###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
 ###
###
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###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###

0 0 0 7
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : JEKY ALI TYPE KUSTA :
ALAMAT : SEREI TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : 2022 TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : YA TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 ALFIAN ALI SEREI 32 L X Z
2 NIDA PUDI SEREI 45 P X Z
3 JULIANI LESTARI ALI SEREI 29 L X Z
4 RETIE PAPIA SEREI 45 P X Z
5 RUDITA PITER PAPIA SEREI 47 L X Z
6 ADINA SAIYANG SEREI 38 L X Z
7 SEREI Z
8 SEREI Z
9 SEREI Z
10 SEREI Z
11 SEREI Z
12 SEREI Z
13 SEREI Z
14 SEREI Z
15 SEREI Z
16 SEREI Z
17 SEREI Z
18 SEREI Z
19 SEREI Z
20 SEREI Z
21 SEREI Z
22 SEREI Z
23 SEREI Z
24 SEREI Z
25 SEREI Z
26 SEREI Z
27 SEREI Z
28 SEREI Z
29 SEREI Z
30 SEREI Z
31 SEREI Z
32 SEREI Z
33 SEREI Z
34 SEREI Z
35 SEREI Z
36 SEREI Z
37 SEREI Z
38 SEREI Z
39 SEREI Z
40 SEREI Z
41 SEREI Z
42 SEREI Z
43 SEREI Z
44 SEREI Z
45 SEREI Z
46 SEREI Z
47 SEREI Z
48 SEREI Z
49 SEREI Z
50 SEREI Z
51 SEREI Z
52 SEREI Z
53 SEREI Z
54 SEREI Z
55 SEREI Z
56 SEREI Z
57 SEREI Z
58 SEREI Z
59 SEREI Z
60 SEREI Z
61 SEREI Z
62 SEREI Z
63 SEREI Z
64 SEREI Z
65 SEREI Z
66 SEREI Z
67 SEREI Z
68 SEREI Z
69 SEREI Z
70 SEREI Z
71 SEREI Z
72 SEREI Z
73 SEREI Z
74 SEREI Z
75 SEREI Z
76 SEREI Z
77 SEREI Z
78 SEREI Z
79 SEREI Z
80 SEREI Z
81 SEREI Z
82 SEREI Z
83 SEREI Z
84 SEREI Z
85 SEREI Z
86 SEREI Z
87 SEREI Z
88 SEREI Z
89 SEREI Z
90 SEREI Z
91 SEREI Z
92 SEREI Z
93 SEREI Z
94 SEREI Z
95 SEREI Z
96 SEREI Z
97 SEREI Z
98 SEREI Z
99 SEREI Z
100 SEREI Z
101 SEREI Z
102 SEREI Z
103 SEREI Z
104 SEREI Z
105 SEREI Z
106 SEREI Z
107 SEREI Z
108 SEREI Z
109 SEREI Z
110 SEREI Z
111 SEREI Z
112 SEREI Z
113 SEREI Z
114 SEREI Z
115 SEREI Z
116 SEREI Z
117 SEREI Z
118 SEREI Z
119 SEREI Z
120 SEREI Z
121 SEREI Z
122 SEREI Z
123 SEREI Z
124 SEREI Z
125 SEREI Z
126 SEREI Z
127 SEREI Z
128 SEREI Z
129 SEREI Z
130 SEREI Z
131 SEREI Z
132 SEREI Z
133 SEREI Z
134 SEREI Z
135 SEREI Z
136 SEREI Z
137 SEREI Z
138 SEREI Z
139 SEREI Z
140 SEREI Z
141 SEREI Z
142 SEREI Z
143 SEREI Z
144 SEREI Z
145 SEREI Z
146 SEREI Z
147 SEREI Z
148 SEREI Z
149 SEREI Z
150 SEREI Z
151 SEREI Z
152 SEREI Z
153 SEREI Z
154 SEREI Z
155 SEREI Z
156 SEREI Z
157 SEREI Z
158 SEREI Z
159 SEREI Z
160 SEREI Z
161 SEREI Z
162 SEREI Z
163 SEREI Z
164 SEREI Z
165 SEREI Z
166 SEREI Z
167 SEREI Z
168 SEREI Z
169 SEREI Z
170 SEREI Z
171 SEREI Z
172 SEREI Z
173 SEREI Z
174 SEREI Z
175 SEREI Z
176 SEREI Z
177 SEREI Z
178 SEREI Z
179 SEREI Z
180 SEREI Z
181 SEREI Z
182 SEREI Z
183 SEREI Z
184 SEREI Z
185 SEREI Z
186 SEREI Z
187 SEREI Z
188 SEREI Z
189 SEREI Z
190 SEREI Z
191 SEREI Z
192 SEREI Z
193 SEREI Z
194 SEREI Z
195 SEREI Z
196 SEREI Z
197 SEREI Z
198 SEREI Z
199 SEREI Z
200 SEREI Z

6 6 3 2 1 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 P
MB
0 PB
SUKARELA MB
###
2022 ###

JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK
SAMPING ###
DALAM
BENTUK MENU ###
USPEK KUSTA SUSPEK TB
###
NEG POS NEG ###
###
###
###
###
###
###
###
###
###
###
 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
PINDAHAN
RELAPS
MASUK KEMBALI
GANTI TYPE
###
###
###
###
###
###
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###

0 0 0 6
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : 2022 TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : YA TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 P
MB
0 PB
SUKARELA MB
###
2020 ###

JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK
SAMPING ###
DALAM
BENTUK MENU ###
USPEK KUSTA SUSPEK TB
###
NEG POS NEG ###
###
###
###
###
###
###
###
###
###
###
 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
PINDAHAN
RELAPS
MASUK KEMBALI
GANTI TYPE
###
###
###
###
###
###
###
###
###
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###
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###
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###
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###
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###
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 ###
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###
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###
###
###
###
###
###
###

0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : MAYA OLONGSONGKE TYPE KUSTA :
ALAMAT : SEREI TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : 2022 TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : YA TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 MEIVI OLONGSONGKE SEREI 24 L X Z
2 MONIKA JULIEN BAWALANG SEREI 15 P X Z
3 SILAS OLONGSONGKE SEREI 64 L X Z
4 ALTIF RIANI MARASI SEREI 28 L X Z
5 ESTEFINA MAKAHINDA SEREI 55 P X Z
6 HILKIA JULIO MARASI SEREI 67 L X Z
7 DINCE WAGIU SEREI 62 P X Z
8 JOICE WONGKAR SEREI 43 P X Z
9 ALFA WONGKAR SEREI 20 P X Z
10 ANGGA WONGKAR SEREI 12 L X Z
11 MAYA WOLLAH SEREI 26 P X Z
12 AGNES PANDELAKI SEREI 3 P X Z
13 CHELLI WOLAH SEREI 52 P X Z
14 ANDRE WEKU SEREI 51 L X Z
15 DONNY WOLLAH SEREI 21 L X Z
16 JELITA WOLLAH SEREI 15 P X Z
17 SEREI Z
18 SEREI Z
19 SEREI Z
20 SEREI Z
21 SEREI Z
22 SEREI Z
23 SEREI Z
24 SEREI Z
25 SEREI Z
26 SEREI Z
27 SEREI Z
28 SEREI Z
29 SEREI Z
30 SEREI Z
31 SEREI Z
32 SEREI Z
33 SEREI Z
34 SEREI Z
35 SEREI Z
36 SEREI Z
37 SEREI Z
38 SEREI Z
39 SEREI Z
40 SEREI Z
41 SEREI Z
42 SEREI Z
43 SEREI Z
44 SEREI Z
45 SEREI Z
46 SEREI Z
47 SEREI Z
48 SEREI Z
49 SEREI Z
50 SEREI Z
51 SEREI Z
52 SEREI Z
53 SEREI Z
54 SEREI Z
55 SEREI Z
56 SEREI Z
57 SEREI Z
58 SEREI Z
59 SEREI Z
60 SEREI Z
61 SEREI Z
62 SEREI Z
63 SEREI Z
64 SEREI Z
65 SEREI Z
66 SEREI Z
67 SEREI Z
68 SEREI Z
69 SEREI Z
70 SEREI Z
71 SEREI Z
72 SEREI Z
73 SEREI Z
74 SEREI Z
75 SEREI Z
76 SEREI Z
77 SEREI Z
78 SEREI Z
79 SEREI Z
80 SEREI Z
81 SEREI Z
82 SEREI Z
83 SEREI Z
84 SEREI Z
85 SEREI Z
86 SEREI Z
87 SEREI Z
88 SEREI Z
89 SEREI Z
90 SEREI Z
91 SEREI Z
92 SEREI Z
93 SEREI Z
94 SEREI Z
95 SEREI Z
96 SEREI Z
97 SEREI Z
98 SEREI Z
99 SEREI Z
100 SEREI Z
101 SEREI Z
102 SEREI Z
103 SEREI Z
104 SEREI Z
105 SEREI Z
106 SEREI Z
107 SEREI Z
108 SEREI Z
109 SEREI Z
110 SEREI Z
111 SEREI Z
112 SEREI Z
113 SEREI Z
114 SEREI Z
115 SEREI Z
116 SEREI Z
117 SEREI Z
118 SEREI Z
119 SEREI Z
120 SEREI Z
121 SEREI Z
122 SEREI Z
123 SEREI Z
124 SEREI Z
125 SEREI Z
126 SEREI Z
127 SEREI Z
128 SEREI Z
129 SEREI Z
130 SEREI Z
131 SEREI Z
132 SEREI Z
133 SEREI Z
134 SEREI Z
135 SEREI Z
136 SEREI Z
137 SEREI Z
138 SEREI Z
139 SEREI Z
140 SEREI Z
141 SEREI Z
142 SEREI Z
143 SEREI Z
144 SEREI Z
145 SEREI Z
146 SEREI Z
147 SEREI Z
148 SEREI Z
149 SEREI Z
150 SEREI Z
151 SEREI Z
152 SEREI Z
153 SEREI Z
154 SEREI Z
155 SEREI Z
156 SEREI Z
157 SEREI Z
158 SEREI Z
159 SEREI Z
160 SEREI Z
161 SEREI Z
162 SEREI Z
163 SEREI Z
164 SEREI Z
165 SEREI Z
166 SEREI Z
167 SEREI Z
168 SEREI Z
169 SEREI Z
170 SEREI Z
171 SEREI Z
172 SEREI Z
173 SEREI Z
174 SEREI Z
175 SEREI Z
176 SEREI Z
177 SEREI Z
178 SEREI Z
179 SEREI Z
180 SEREI Z
181 SEREI Z
182 SEREI Z
183 SEREI Z
184 SEREI Z
185 SEREI Z
186 SEREI Z
187 SEREI Z
188 SEREI Z
189 SEREI Z
190 SEREI Z
191 SEREI Z
192 SEREI Z
193 SEREI Z
194 SEREI Z
195 SEREI Z
196 SEREI Z
197 SEREI Z
198 SEREI Z
199 SEREI Z
200 SEREI Z

16 16 7 7 2 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
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0 0 0 16
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : 2020 TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : YA TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

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TERAKHIR MRS HATI/GINJAL
POS

1 0 Z

2 0 Z

3 0 Z

4 0 Z
5 0 Z
6 0 Z
7 0 Z
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9 0 Z
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11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
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26 0 Z
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28 0 Z
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37 0 Z
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110 0 Z
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113 0 Z
114 0 Z
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121 0 Z
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126 0 Z
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131 0 Z
132 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : 2021 TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : YA TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z

15 0 Z

16 0 Z
17 0 Z
18 0 Z

19 0 Z

20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
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53 0 Z
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55 0 Z
56 0 Z
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60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
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76 0 Z
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79 0 Z
80 0 Z
81 0 Z
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108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
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156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
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169 0 Z
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173 0 Z
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176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
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PAPUTUNGAN
TEREMAAL
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0 PB
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JUMLAH KONFIRMASI
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NEG POS NEG ###
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : 2021 TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : YA TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
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46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
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84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
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90 0 Z
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92 0 Z
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94 0 Z
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96 0 Z
97 0 Z
98 0 Z
99 0 Z
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103 0 Z
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105 0 Z
106 0 Z
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108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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ALAMAT : TINGKAT CACAT :
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TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
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9 0 Z
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12 0 Z
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14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
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23 0 Z
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25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
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36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
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50 0 Z
51 0 Z
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53 0 Z
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59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
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67 0 Z
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75 0 Z
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77 0 Z
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79 0 Z
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83 0 Z
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98 0 Z
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108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
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121 0 Z
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123 0 Z
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125 0 Z
126 0 Z
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128 0 Z
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130 0 Z
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132 0 Z
133 0 Z
134 0 Z
135 0 Z
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137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
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145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
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155 0 Z
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157 0 Z
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179 0 Z
180 0 Z
181 0 Z
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191 0 Z
192 0 Z
193 0 Z
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197 0 Z
198 0 Z
199 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

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TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
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6 0 Z
7 0 Z
8 0 Z
9 0 Z
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11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
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22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
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30 0 Z
31 0 Z
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36 0 Z
37 0 Z
38 0 Z
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53 0 Z
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59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
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67 0 Z
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75 0 Z
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83 0 Z
84 0 Z
85 0 Z
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97 0 Z
98 0 Z
99 0 Z
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107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
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128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
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137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
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146 0 Z
147 0 Z
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150 0 Z
151 0 Z
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156 0 Z
157 0 Z
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162 0 Z
163 0 Z
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179 0 Z
180 0 Z
181 0 Z
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187 0 Z
188 0 Z
189 0 Z
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191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
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0 PB
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

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M S
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
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12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
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36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
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47 0 Z
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60 0 Z
61 0 Z
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64 0 Z
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67 0 Z
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77 0 Z
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79 0 Z
80 0 Z
81 0 Z
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84 0 Z
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97 0 Z
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99 0 Z
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103 0 Z
104 0 Z
105 0 Z
106 0 Z
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108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
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121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
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132 0 Z
133 0 Z
134 0 Z
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137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
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169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
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83 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
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SONSILO
TANAH PUTIH
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YA
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
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25 0 Z
26 0 Z
27 0 Z
28 0 Z
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30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
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38 0 Z
39 0 Z
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41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
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69 0 Z
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73 0 Z
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75 0 Z
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77 0 Z
78 0 Z
79 0 Z
80 0 Z
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83 0 Z
84 0 Z
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86 0 Z
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88 0 Z
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102 0 Z
103 0 Z
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105 0 Z
106 0 Z
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108 0 Z
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112 0 Z
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114 0 Z
115 0 Z
116 0 Z
117 0 Z
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119 0 Z
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123 0 Z
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126 0 Z
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146 0 Z
147 0 Z
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150 0 Z
151 0 Z
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179 0 Z
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189 0 Z
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192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
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PAPUTUNGAN
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 0 PB
SUKARELA MB
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JUMLAH KONFIRMASI
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
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TERAKHIR MRS HATI/GINJAL
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1 0 Z
2 0 Z
3 0 Z
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6 0 Z
7 0 Z
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12 0 Z
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14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
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20 0 Z
21 0 Z
22 0 Z
23 0 Z
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25 0 Z
26 0 Z
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28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
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36 0 Z
37 0 Z
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55 0 Z
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60 0 Z
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77 0 Z
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79 0 Z
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108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
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120 0 Z
121 0 Z
122 0 Z
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124 0 Z
125 0 Z
126 0 Z
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128 0 Z
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132 0 Z
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138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
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156 0 Z
157 0 Z
158 0 Z
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160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
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166 0 Z
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172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
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179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
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GANGGA 1
GANGGA 2
TAMBUN
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 0 PB
MB
###
###

JUMLAH KONFIRMASI
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USPEK KUSTA SUSPEK TB
###
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
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30 0 Z
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32 0 Z
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60 0 Z
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106 0 Z
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108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
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130 0 Z
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132 0 Z
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138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
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156 0 Z
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158 0 Z
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161 0 Z
162 0 Z
163 0 Z
164 0 Z
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169 0 Z
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172 0 Z
173 0 Z
174 0 Z
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179 0 Z
180 0 Z
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184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
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TAMBUN
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.
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.
 0 PB
MB
###
###

JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 X Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
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47 0 Z
48 0 Z
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50 0 Z
51 0 Z
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53 0 Z
54 0 Z
55 0 Z
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59 0 Z
60 0 Z
61 0 Z
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113 0 Z
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198 0 Z
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0 0 1 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
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PAPUTUNGAN
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YA
JUMLAH KONFIRMASI
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0 0 0 1
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
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36 0 Z
37 0 Z
38 0 Z
39 0 Z
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41 0 Z
42 0 Z
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47 0 Z
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51 0 Z
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53 0 Z
54 0 Z
55 0 Z
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59 0 Z
60 0 Z
61 0 Z
62 0 Z
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64 0 Z
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67 0 Z
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77 0 Z
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79 0 Z
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84 0 Z
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86 0 Z
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97 0 Z
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99 0 Z
100 0 Z
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102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
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108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
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132 0 Z
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134 0 Z
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139 0 Z
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146 0 Z
147 0 Z
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150 0 Z
151 0 Z
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163 0 Z
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174 0 Z
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180 0 Z
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192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
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200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
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GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
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WAWUNIAN
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YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
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36 0 Z
37 0 Z
38 0 Z
39 0 Z
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108 0 Z
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110 0 Z
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112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
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121 0 Z
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123 0 Z
124 0 Z
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126 0 Z
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128 0 Z
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139 0 Z
140 0 Z
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151 0 Z
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193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
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YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
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36 0 Z
37 0 Z
38 0 Z
39 0 Z
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41 0 Z
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53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
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84 0 Z
85 0 Z
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108 0 Z
109 0 Z
110 0 Z
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112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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TERAKHIR MRS HATI/GINJAL
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6 0 Z
7 0 Z
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12 0 Z
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23 0 Z
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28 0 Z
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31 0 Z
32 0 Z
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38 0 Z
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41 0 Z
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MUNTE
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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TERAKHIR MRS HATI/GINJAL
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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TARABITAN
SONSILO
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

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M S
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TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
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7 0 Z
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9 0 Z
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12 0 Z
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14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
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20 0 Z
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23 0 Z
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194 0 Z
195 0 Z
196 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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MUBUNE
BAHOI
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TARABITAN
SONSILO
TANAH PUTIH
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JUMLAH KONFIRMASI
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
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TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
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150 0 Z
151 0 Z
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163 0 Z
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165 0 Z
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169 0 Z
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173 0 Z
174 0 Z
175 0 Z
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179 0 Z
180 0 Z
181 0 Z
182 0 Z
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189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
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 PB
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YA
JUMLAH KONFIRMASI
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
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170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
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179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
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GANGGA 1
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TAMBUN
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 PB
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YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
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.
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 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
SAMPING ###
DALAM
USPEK KUSTA SUSPEK TB BENTUK MENU ###
###
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ANAK SEKOLAH
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
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73 0 Z
74 0 Z
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77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
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102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
SAMPING ###
DALAM
BENTUK ###
USPEK KUSTA SUSPEK TB MENU
###
NEG POS NEG ###
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KONTAK SERUMAH
ANAK SEKOLAH
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
SAMPING ###
DALAM
BENTUK MENU ###
USPEK KUSTA SUSPEK TB
###
NEG POS NEG ###
###
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 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
PINDAHAN
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###
###
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
SAMPING ###
DALAM
USPEK KUSTA SUSPEK TB BENTUK MENU ###
###
NEG POS NEG ###
###
###
###
###
###
###
###
###
###
###
 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
PINDAHAN
RELAPS
MASUK KEMBALI
GANTI TYPE
###
###
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
 1 MUNTE
2 BULUTUI
3 MUBUNE
4 BAHOI
5 SEREI
6 TARABITAN
7 SONSILO
8 TANAH PUTIH
9 JAYAKARSA
10 PAPUTUNGAN
11 TEREMAAL
12 MALIAMBAO
13 PALAES
14 GANGGA 1
15 GANGGA 2
16 TAMBUN
17 AIRBANUA
18 TALISE
19 KINABUHUTAN
20 WAWUNIAN
21 .
22 .
23 .
24 .
25 .
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
SAMPING ###
DALAM
BENTUK ###
USPEK KUSTA SUSPEK TB
MENU ###
NEG POS NEG ###
###
###
###
###
###
###
###
###
###
###
 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
PINDAHAN
RELAPS
MASUK KEMBALI
GANTI TYPE
###
###
###
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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TERAKHIR MRS HATI/GINJAL
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MUNTE
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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ALAMAT : TINGKAT CACAT :
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TERAKHIR MRS HATI/GINJAL
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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BAHOI
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JUMLAH KONFIRMASI
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

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TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
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12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
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141 0 Z
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150 0 Z
151 0 Z
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155 0 Z
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179 0 Z
180 0 Z
181 0 Z
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188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
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TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
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93 0 Z
94 0 Z
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97 0 Z
98 0 Z
99 0 Z
100 0 Z
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102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
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137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
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144 0 Z
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146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
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155 0 Z
156 0 Z
157 0 Z
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179 0 Z
180 0 Z
181 0 Z
182 0 Z
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189 0 Z
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193 0 Z
194 0 Z
195 0 Z
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197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
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JUMLAH KONFIRMASI
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
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TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
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44 0 Z
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46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
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59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
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73 0 Z
74 0 Z
75 0 Z
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77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
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83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
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94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
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GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
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 PB
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YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
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47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
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53 0 Z
54 0 Z
55 0 Z
56 0 Z
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59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
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74 0 Z
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78 0 Z
79 0 Z
80 0 Z
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84 0 Z
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99 0 Z
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103 0 Z
104 0 Z
105 0 Z
106 0 Z
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108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
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160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
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178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
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GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
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 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
SAMPING ###
DALAM
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IDENTITAS KASUS INDEKS JENIS KELAMIN :

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TERAKHIR MRS HATI/GINJAL
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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IDENTITAS KASUS INDEKS JENIS KELAMIN :

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TERAKHIR MRS HATI/GINJAL
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112 0 Z
113 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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TERAKHIR MRS HATI/GINJAL
POS
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2 0 Z
3 0 Z
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6 0 Z
7 0 Z
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9 0 Z
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12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
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20 0 Z
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23 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

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TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
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6 0 Z
7 0 Z
8 0 Z
9 0 Z
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12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
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22 0 Z
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32 0 Z
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60 0 Z
61 0 Z
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64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
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75 0 Z
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77 0 Z
78 0 Z
79 0 Z
80 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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TERAKHIR MRS HATI/GINJAL
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
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IDENTITAS KASUS INDEKS JENIS KELAMIN :

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0 0 0 0 0 0 0 0 0 0 0 0 0
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
SAMPING ###
DALAM
USPEK KUSTA SUSPEK TB BENTUK MENU ###
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NEG POS NEG ###
###
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 SUKARELA
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
SAMPING ###
DALAM
USPEK KUSTA SUSPEK TB BENTUK MENU ###
###
NEG POS NEG ###
###
###
###
###
###
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###
###
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 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
PINDAHAN
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GANTI TYPE
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
SAMPING ###
DALAM
USPEK KUSTA SUSPEK TB BENTUK MENU ###
###
NEG POS NEG ###
###
###
###
###
###
###
###
###
###
###
 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
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GANTI TYPE
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
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JUMLAH KONFIRMASI
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USPEK KUSTA SUSPEK TB
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
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46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
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74 0 Z
75 0 Z
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77 0 Z
78 0 Z
79 0 Z
80 0 Z
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83 0 Z
84 0 Z
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97 0 Z
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103 0 Z
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105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
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121 0 Z
122 0 Z
123 0 Z
124 0 Z
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126 0 Z
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128 0 Z
129 0 Z
130 0 Z
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132 0 Z
133 0 Z
134 0 Z
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139 0 Z
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141 0 Z
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151 0 Z
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179 0 Z
180 0 Z
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188 0 Z
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192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
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GANGGA 1
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TAMBUN
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KINABUHUTAN
WAWUNIAN
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 PB
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YA
JUMLAH KONFIRMASI
DIAGNOSA ADA TIDAK
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BENTUK MENU ###
USPEK KUSTA SUSPEK TB
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : 2018 TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK TIDAK
SAMPING ###
DALAM
BENTUK ###
USPEK KUSTA SUSPEK TB MENU ###
NEG POS NEG ###
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 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : 2018 TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
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84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK TIDAK
SAMPING ###
DALAM
USPEK KUSTA SUSPEK TB BENTUK MENU ###
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KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
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INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

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M S
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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
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2 0 Z
3 0 Z
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5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
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12 0 Z
13 0 Z
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35 0 Z
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59 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
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 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
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IDENTITAS KASUS INDEKS JENIS KELAMIN :

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SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
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25 0 Z
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78 0 Z
79 0 Z
80 0 Z
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105 0 Z
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108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
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121 0 Z
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123 0 Z
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126 0 Z
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128 0 Z
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132 0 Z
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141 0 Z
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146 0 Z
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150 0 Z
151 0 Z
152 0 Z
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173 0 Z
174 0 Z
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179 0 Z
180 0 Z
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185 0 Z
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188 0 Z
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192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
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JUMLAH KONFIRMASI
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

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TERAKHIR MRS HATI/GINJAL
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2 0 Z
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7 0 Z
8 0 Z
9 0 Z
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12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
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23 0 Z
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25 0 Z
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28 0 Z
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30 0 Z
31 0 Z
32 0 Z
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113 0 Z
114 0 Z
115 0 Z
116 0 Z
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192 0 Z
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194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
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0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
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YA
JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK TIDAK
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
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155 0 Z
156 0 Z
157 0 Z
158 0 Z
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160 0 Z
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169 0 Z
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171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
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187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
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TAMBUN
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WAWUNIAN
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 PB
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###
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YA
JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK TIDAK
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
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 PB
MB
###
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YA
JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK TIDAK
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
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94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
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178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
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GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
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 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK TIDAK
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USPEK KUSTA SUSPEK TB BENTUK MENU ###
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
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 PB
MB
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YA
JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK TIDAK
SAMPING ###
DALAM
USPEK KUSTA SUSPEK TB BENTUK MENU ###
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NEG POS NEG ###
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 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
PINDAHAN
RELAPS
MASUK KEMBALI
GANTI TYPE
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK YG KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI

U DIBERI KEMOPROFILAKSIS ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S
NO NAMA ALAMAT U E
R X
USIA <2 PERNAH MINUM SAKIT GANGGUAN SUSPEK SUSPEK SEBAB SUSPEK KUSTA
SERUMAH TETANGGA SOSIAL Thn RIF. < 2 Thn BERAT/ FUNGSI KUSTA TB LAIN
TERAKHIR MRS HATI/GINJAL
POS
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z

0 0 0 0 0 0 0 0 0 0 0 0 0
MUNTE
BULUTUI
MUBUNE
BAHOI
SEREI
TARABITAN
SONSILO
TANAH PUTIH
JAYAKARSA
PAPUTUNGAN
TEREMAAL
MALIAMBAO
PALAES
GANGGA 1
GANGGA 2
TAMBUN
AIRBANUA
TALISE
KINABUHUTAN
WAWUNIAN
.
.
.
.
.
 PB
MB
###
###

YA
JUMLAH KONFIRMASI
DIAGNOSA ADA EFEK TIDAK
SAMPING ###
DALAM
###
USPEK KUSTA SUSPEK TB BENTUK MENU
###
NEG POS NEG ###
###
###
###
###
###
###
###
###
###
###
 SUKARELA
KONTAK SERUMAH
ANAK SEKOLAH
AKTIF LAIN
PINDAHAN
RELAPS
MASUK KEMBALI
GANTI TYPE
###
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0 0 0 0
 DAFTAR PEMBERIAN KEMOPROFILAKSIS KUSTA METODE KONTAK
TAHUN 2023

IDENTITAS KASUS INDEKS JENIS KELAMIN :

NAMA : TYPE KUSTA :
ALAMAT : TINGKAT CACAT :
PUSKESMAS : PUSKESMAS MUBUNE JENIS PENEMUAN :
TAHUN PENEMUAN : TANGGAL PELAKSANAAN :
APAKAH SUDAH ADA PEMERIKSAAN KONTAK : TAHUN PEMBERIAN SDR :

INFORMASI KONTAK
YG DIBERI KONTAK TIDAK DIBERI KEMOPROFIAKSIS DENGAN JUMLAH KONFIRMASI
U ALASAN/ EKSLUSIF KARENA DIAGNOSA
M S KEMOPROFILAKSIS
NO NAMA ALAMAT U E
R X PERNAH SUSPEK
SE USIA MINUM RIF. SAKIT GANGGUAN SUSPEK SUSPEK SEBAB KUSTA
SUSPEK TB
RUMAH TETANGGA SOSIAL <2 Thn < 2 Thn BERAT/ FUNGSI HATI KUSTA TB LAIN
TERAKHIR MRS /GINJAL
POS NEG POS NEG
1 0 Z
2 0 Z
3 0 Z
4 0 Z
5 0 Z
6 0 Z
7 0 Z
8 0 Z
9 0 Z
10 0 Z
11 0 Z
12 0 Z
13 0 Z
14 0 Z
15 0 Z
16 0 Z
17 0 Z
18 0 Z
19 0 Z
20 0 Z
21 0 Z
22 0 Z
23 0 Z
24 0 Z
25 0 Z
26 0 Z
27 0 Z
28 0 Z
29 0 Z
30 0 Z
31 0 Z
32 0 Z
33 0 Z
34 0 Z
35 0 Z
36 0 Z
37 0 Z
38 0 Z
39 0 Z
40 0 Z
41 0 Z
42 0 Z
43 0 Z
44 0 Z
45 0 Z
46 0 Z
47 0 Z
48 0 Z
49 0 Z
50 0 Z
51 0 Z
52 0 Z
53 0 Z
54 0 Z
55 0 Z
56 0 Z
57 0 Z
58 0 Z
59 0 Z
60 0 Z
61 0 Z
62 0 Z
63 0 Z
64 0 Z
65 0 Z
66 0 Z
67 0 Z
68 0 Z
69 0 Z
70 0 Z
71 0 Z
72 0 Z
73 0 Z
74 0 Z
75 0 Z
76 0 Z
77 0 Z
78 0 Z
79 0 Z
80 0 Z
81 0 Z
82 0 Z
83 0 Z
84 0 Z
85 0 Z
86 0 Z
87 0 Z
88 0 Z
89 0 Z
90 0 Z
91 0 Z
92 0 Z
93 0 Z
94 0 Z
95 0 Z
96 0 Z
97 0 Z
98 0 Z
99 0 Z
100 0 Z
101 0 Z
102 0 Z
103 0 Z
104 0 Z
105 0 Z
106 0 Z
107 0 Z
108 0 Z
109 0 Z
110 0 Z
111 0 Z
112 0 Z
113 0 Z
114 0 Z
115 0 Z
116 0 Z
117 0 Z
118 0 Z
119 0 Z
120 0 Z
121 0 Z
122 0 Z
123 0 Z
124 0 Z
125 0 Z
126 0 Z
127 0 Z
128 0 Z
129 0 Z
130 0 Z
131 0 Z
132 0 Z
133 0 Z
134 0 Z
135 0 Z
136 0 Z
137 0 Z
138 0 Z
139 0 Z
140 0 Z
141 0 Z
142 0 Z
143 0 Z
144 0 Z
145 0 Z
146 0 Z
147 0 Z
148 0 Z
149 0 Z
150 0 Z
151 0 Z
152 0 Z
153 0 Z
154 0 Z
155 0 Z
156 0 Z
157 0 Z
158 0 Z
159 0 Z
160 0 Z
161 0 Z
162 0 Z
163 0 Z
164 0 Z
165 0 Z
166 0 Z
167 0 Z
168 0 Z
169 0 Z
170 0 Z
171 0 Z
172 0 Z
173 0 Z
174 0 Z
175 0 Z
176 0 Z
177 0 Z
178 0 Z
179 0 Z
180 0 Z
181 0 Z
182 0 Z
183 0 Z
184 0 Z
185 0 Z
186 0 Z
187 0 Z
188 0 Z
189 0 Z
190 0 Z
191 0 Z
192 0 Z
193 0 Z
194 0 Z
195 0 Z
196 0 Z
197 0 Z
198 0 Z
199 0 Z
200 0 Z
ADA EFEK
SAMPING
DALAM
BENTUK